Effect of intravitreal injection of bevacizumab in treated and untreated eyes of Black African patients with polypoidal choroidal vasculopathy.

OBJECTIVE: To evaluate the response of polypoidal choroidal vasculopathy (PCV) in eyes treated with intravitreal bevacizumab (BVZ) and untreated fellow eyes in black Africans. METHODS: We studied 22 eyes (12 patients) divided into 12 treated and 10 untreated eyes from January 2017 to January 2020. Treated eyes received 1 monthly injection of BVZ 2.5mg for 3 months, with optional additional injections depending on the patient's course. Both groups of eyes were evaluated at presentation and then at 3, 6, 9, and 12 months after treatment. Outcome measures were visual acuity (VA) and ophthalmoscopic and OCT findings. RESULTS: The mean age of the patients was 66.3±5.6 years. In treated eyes, VA remained stable from 0.10±0.12 at baseline to 0.20±0.30 at month 12, P=0.84. VA was stable in 83.3% and improved in 16.7% of eyes. On OCT, 41.7% of eyes showed decreased and another 41.7% disappearance of subretinal fluid (SRF) at 12 months. Pigment epithelial detachment (PED) height decreased in 9 eyes (75.0%) but remained unchanged in 3 eyes (25%). In untreated eyes, no difference was observed between the baseline (0.53±0.42) and 12-month VA (0.58±0.40), P=0.82. VA improved in 2 eyes, decreased in one eye, and remained unchanged in 7 eyes. OCT lesions remained stable in 6 eyes. The PED enlarged in one eye but remained stable in 3 other eyes. CONCLUSION: Intravitreal injection of BVZ 2.5mg led to stabilization of VA, resorption of SRF, and reduction in the size of the PED in the majority of eyes with PCV but was ineffective on the polyps. The one-year prognosis in untreated eyes with PCV was favorable and marked by functional and structural stability.

Quality of timolol eye drops marketed in Kinshasa, Democratic Republic of the Congo.

OBJECTIVE: To assess the quality of timolol eye drops sold in Kinshasa, Democratic Republic of Congo (DRC). METHODS: Seven samples of timolol maleate 0.5% were purchased over the counter in seven randomly selected public pharmacies in 3 neighborhoods in Kinshasa. They were submitted to a quality assessment that included visual inspection, spectrophotometry, high performance liquid chromatography (HPLC), and bacteriologic assessment. RESULTS: The samples came from France (n=2), India (n=2) and DRC (n=3). Overall, 3 (2 from India and 1 from the DRC) of the 7 samples, or 3 out of the 5 from developing countries, showed various abnormalities consistent with substandard drugs. One sample (India) demonstrated an incorrect pH, while 3 (2 from India and one from the DRC) had lower than stated volumes as well as lower than required concentrations of the active pharmaceutical ingredient. In addition, one sample from the DRC was bacteriologically contaminated. CONCLUSION: These results suggest that some timolol maleate eye drops from Congolese and Indian manufacturers sold in Kinshasa are of substandard quality. This may reflect deficiencies in the manufacturers and local authorities charged with regulation of the quality control and sale of pharmaceuticals. Passing a visual inspection does not necessarily indicate that a drug is not substandard. Analytical chemistry testing and bacteriologic analysis are required to determine with certainty the quality of the drug.

A comparison of cup-to-disc ratio estimates by fundus biomicroscopy and stereoscopic optic disc photography in the Tema Eye Survey.

PurposeTo determine if there are systematic differences in cup-to-disc ratio (CDR) grading using fundus biomicroscopy compared to stereoscopic disc photograph reading.MethodsThe vertical cup-to-disc ratio (VCDR) and horizontal cup-to-disc ratio (HCDR) of 2200 eyes (testing set) were graded by glaucoma subspecialists through fundus biomicroscopy and by a reading center using stereoscopic disc photos. For validation, the glaucoma experts also estimated VCDR and HCDR using stereoscopic disc photos in a subset of 505 eyes that they had assessed biomicroscopically. Agreement between grading methods was assessed with Bland-Altman plots.ResultsIn both sets, photo reading tended to yield small CDRs marginally larger, but read large CDRs marginally smaller than fundus biomicroscopy. The mean differences in VCDR and HCDR were 0.006±0.18 and 0.05±0.18 (testing set), and -0.053±0.23 and -0.028±0.21 (validation set), respectively. The limits of agreement were ~0.4, which is twice as large as the cutoff of clinically significant CDR difference between methods. CDR estimates differed by 0.2 or more in 33.8-48.7% between methods.ConclusionsThe differences in CDR estimates between fundus biomicroscopy and stereoscopic optic disc photo reading showed a wide variation, and reached clinically significance threshold in a large proportion of patients, suggesting a poor agreement. Thus, glaucoma should be monitored by comparing baseline and subsequent CDR estimates using the same method rather than comparing photographs to fundus biomicroscopy.

Attitudes of primary health care providers towards people with mental illness: evidence from two districts in Zambia.

OBJECTIVE: The aim of this study was to explore health care providers' attitudes towards people with mental illness within two districts in Zambia. It sought to document types of attitudes of primary health care providers towards people suffering from mental illness and possible predictors of such attitudes. This study offers insights into how health care providers regard people with mental illness that may be helpful in designing appropriate training or re-training programs in Zambia and other low-income African countries. METHOD: Using a pilot tested structured questionnaire, data were collected from a total of 111 respondents from health facilities in the two purposively selected districts in Zambia that the Ministry of Health has earmarked as pilot districts for integrating mental health into primary health care. RESULTS: There are widespread stigmatizing and discriminatory attitudes among primary health care providers toward mental illness and those who suffer from it. These findings confirm and add weight to the results from the few other studies which have been conducted in Africa that have challenged the notion that stigma and discrimination of mental illness is less severe in African countries. CONCLUSION: There is an urgent need to start developing more effective awareness-raising, training and education programmes amongst health care providers. This will only be possible if there is increased consensus, commitment and political will within government to place mental health on the national agenda and secure funding for the sector. These steps are essential if the country is improve the recognition, diagnosis and treatment of mental disorders, and realize the ideals enshrined in the progressive health reforms undertaken over the last decade.

Mental illness--stigma and discrimination in Zambia.

OBJECTIVE: The aim of this qualitative study was to explore the presence, causes and means of addressing individual and systemic stigma and discrimination against people with mental illness in Zambia. This is to facilitate the development of tailor-made antistigma initiatives that are culturally sensitive for Zambia and other low-income African countries. This is the first in-depth study on mental illness stigma in Zambia. METHOD: Fifty semi-structured interviews and 6 focus group discussions were conducted with key stakeholders drawn from 3 districts in Zambia (Lusaka, Kabwe and Sinazongwe). Transcripts were analyzed using a grounded theory approach. RESULTS: Mental illness stigma and discrimination is pervasive across Zambian society, prevailing within the general community, amongst family members, amid general and mental health care providers, and at the level of government. Such stigma appears to be fuelled by misunderstandings of mental illness aetiology; fears of contagion and the perceived dangerousness of people with mental illness; and associations between HIV/AIDS and mental illness. Strategies suggested for reducing stigma and discrimination in Zambia included education campaigns, the transformation of mental health policy and legislation and expanding the social and economic opportunities of the mentally ill. CONCLUSION: In Zambia, as in many other low-income African countries, very little attention is devoted to addressing the negative beliefs and behaviours surrounding mental illness, despite the devastating costs that ensue. The results from this study underscore the need for greater commitment from governments and policy-makers in African countries to start prioritizing mental illness stigma as a major public health and development issue.

Mental illness - stigma and discrimination in Zambia

Objective: The aim of this qualitative study was to explore the presence; causes and means of addressing individual and systemic stigma and discrimination against people with mental illness in Zambia. This is to facilitate the development of tailor-made antistigma initiatives that are culturally sensitive for Zambia and other low-income African countries. This is the first in-depth study on mental illness stigma in Zambia. Method: Fifty semi-structured interviews and 6 focus group discussions were conducted with key stakeholders drawn from 3 districts in Zambia (Lusaka; Kabwe and Sinazongwe). Transcripts were analyzed using a grounded theory approach. Results: Mental illness stigma and discrimination is pervasive across Zambian society; prevailing within the general community; amongst family members; amid general and mental health care providers; and at the level of government. Such stigma appears to be fuelled by misunderstandings of mental illness aetiology; fears of contagion and the perceived dangerousness of people with mental illness; and associations between HIV/AIDS and mental illness. Strategies suggested for reducing stigma and discrimination in Zambia included education campaigns; the transformation of mental health policy and legislation and expanding the social and economic opportunities of the mentally ill. Conclusion: In Zambia; as in many other lowincome African countries; very little attention is devoted to addressing the negative beliefs and behaviours surrounding mental illness; despite the devastating costs that ensue. The results from this study underscore the need for greater commitment from governments and policy-makers in African countries to start prioritizing mental illness stigma as a major public health and development issue

Lacrimal drainage obstruction by Ascaris lumbricoides.

Lacrimal drainage obstruction by Ascaris lumbricoides is extremely rare and only few cases have been documented. We report an additional case from the Democratic Republic of Congo.

Neuro-ophthalmological disorders in HIV infected subjects with neurological manifestations.

AIMS: To determine the frequency and features of neuro-ophthalmological manifestations in neurologically symptomatic HIV infected patients and to assess whether or not the visual evoked potential (VEP) features in these patients differ from those of neurologically asymptomatic HIV infected patients. METHODS: Neuro-ophthalmological evaluation was performed in 166 neurologically symptomatic confirmed HIV positive patients, of whom 75 with normal ophthalmological examination were further studied by means of VEPs. The VEPs values were compared to those obtained from 53 other confirmed HIV positive subjects with neither ophthalmological nor neurological manifestations, who served as a comparison group and to the references values of our laboratory. RESULTS: An abnormal neuro-ophthalmological examination was noted in 99/166 patients (60%). Eye movement disorders were present in 99 patients (51%). Visual field defects were detected in 39% of the patients. Optic neuropathy was noted in 31%, papilloedema in 27% and ocular motor nerve palsies in 26% of the patients. Toxoplasmosis and cryptococcosis were the most frequent associated pathologies, though in some patients the HIV itself was the presumed cause. VEPs were abnormal in 57% and 42% of patients with and without neurological manifestations, respectively. Compared to asymptomatic patients, symptomatic patients had a significantly increased mean latency; however, both groups had significant increase in mean latency compared to reference values. CONCLUSION: Neuro-ophthalmological manifestations are common in neurologically symptomatic HIV infected patients. Subclinical dysfunction in the visual pathways is a common phenomenon in both HIV infected patients with and without neurological symptoms, but neurologically symptomatic patients seem to have more damage in their visual pathways.

Visual evoked potentials in konzo, a spastic paraparesis of acute onset in Africa.

AIM: To assess whether or not visual evoked potentials (VEPs) are abnormal in konzo, a para/tetraparesis of sudden onset, and to correlate the findings to the clinical picture of the disorder. METHODS: VEPs were recorded in 23 patients (9 men and 14 women, mean age: 23 +/- 10 years) suffering from konzo, and 38 healthy subjects (20 men and 18 women, mean age: 27 +/- 15 years). The mean P100 latencies and peak-to-peak N75-P100 amplitudes of each eye were measured and compared in the two groups. The mean interocular P100 latency and amplitude differences were calculated and also compared. RESULTS: VEPs were abnormal in 11/23 patients (48%) consisting of P100 prolongation (7 subjects), absence of P100 wave (2 subjects) or an atypical waveform (2 subjects). The mean P100 latency value of the konzo group was significantly increased as compared with the mean (+ 2.5 SD) of the reference values from healthy subjects (p < 0.05). There was a statistically significant decrease of amplitude in konzo patients compared to normal subjects (p < 0.05) with, however, only 2 patients outside the 95% confidence limits. Six patients (27%) had abnormal VEPs despite normal visual acuity. These abnormalities were symmetric and a relation could be found between neither the duration nor the severity of the disease and the VEP perturbation. CONCLUSION: The main features of these abnormalities are delayed P100 latency and decreased amplitude. These findings indicate involvement of visual pathways and seem to suggest the presence of axonal loss in the prechiasmal visual pathways in konzo. This study provides evidence that the neurodamage in konzo extends to the visual pathways.

Neuro-ophthalmologic findings in konzo, an upper motor neuron disorder in Africa.

PURPOSE: To investigate the neuro-ophthalmological manifestations in konzo, a non-progressive symmetric spastic para/tetraparesis of acute onset associated with consumption of insufficiently processed bitter cassava roots combined with a low protein intake. METHODS: Twenty-one Congolese konzo patients underwent neuro-ophthalmological investigations including visual acuity testing, assessment of light pupillary reflexes, evaluation of ocular motility and deviation, direct ophthalmoscopy, and visual field perimetry. Objective refraction including retinoscopy and keratometry, and slit-lamp biomicroscopy were also done. RESULTS: Five patients had visual impairment, and 14 had temporal pallor of the optic disc. Fourteen presented visual field defects, the most frequent being concentric constriction and peripheral defects. Overall, 11 subjects had symptoms qualifying for the diagnosis of optic neuropathy. Two had spontaneous pendular nystagmus in primary position of gaze. Visual field defects and pallor of the optic discs were found in mild, moderate and severe forms of konzo. No correlation was found between the severity of the motor disability of konzo and the extent of visual field loss. CONCLUSIONS: Konzo was associated with optic neuropathy and a few patients had nystagmus. Although the etiopathogenesis of this optic neuropathy remains to be elucidated, the symmetry of the involvement suggests a toxic origin. We suggest that cyanide causes the neuro-ophthalmological damage in konzo. However, the optic neuropathy in konzo patients does not resemble the features of the epidemic optic neuropathy in Tanzania, Cuba or Nigeria, Leber's hereditary optic neuropathy, tobacco amblyopia or vitamin B deficiency.

Profile of eye lesions and vision loss: a cross-sectional study in Lusambo, a forest-savanna area hyperendemic for onchocerciasis in the Democratic Republic of Congo.

OBJECTIVE: To determine baseline data regarding eye lesions and vision loss in five villages of Lusambo, an onchocerciasis-hyperendemic forest-savanna area in the Democratic Republic of Congo (DRC), in preparation of mass ivermectin distribution. METHODS: Five villages were selected by simple randomization. Through a cross-sectional design, 750 subjects were examined ophthalmologically. The eye examination included acuity visual measurement, slit-lamp examination, ophthalmoscopy, intraocular pressure measurement, and visual field assessment by the Wu-Jones test. RESULTS: There was a high prevalence of onchocerciasis-related eye lesions compared with non-onchocercal lesions. Chorioretinitis (20%) was the most frequent disease, others were punctate keratitis and microfilariae in the anterior chamber in equal frequency (13.8%), white intraretinal deposits (10.4%) and iridocyclitis (8%). Vision loss was discovered in 8.5% of the subjects, of whom 0.5% had bilateral blindness, 2.2% had monocular blindness and 5.7% had visual impairment. Vision loss was mostly caused by onchocerciasis-related diseases, especially those affecting the anterior segment of the eye. CONCLUSION: Features of ocular onchocerciasis usually described in forest and savanna areas were both found in this forest-savanna zone of the DRC.

Amodiaquine-artesunate versus amodiaquine for uncomplicated Plasmodium falciparum malaria in African children: a randomised, multicentre trial.

BACKGROUND: Increasing drug resistance limits the choice of efficacious chemotherapy against Plasmodium falciparum malaria in Africa. Amodiaquine still retains efficacy against P falciparum in many African countries. We assessed the safety, treatment efficacy, and effect on gametocyte carriage of adding artesunate to amodiaquine in three randomised trials in Kenya, Sénégal, and Gabon. METHODS: We enrolled 941 children (400 in Kenya, 321 in Sénégal, and 220 in Gabon) who were 10 years or older and who had uncomplicated P falciparum malaria. Patients were randomly assigned amodiaquine (10 mg/kg per day for 3 days) plus artesunate (4 mg/kg per day for 3 days) or amodiaquine (as above) and placebo (for 3 days). The primary endpoints were parasitological cure rates at days 14 and 28. Analysis was by intention to treat and by an evaluability method. FINDINGS: Both regimens were well tolerated. Six patients in the amodiaquine-artesunate group and five in the amodiaquine group developed early, drug-induced vomiting, necessitating alternative treatment. By intention-to-treat analysis, the day-14 cure rates for amodiaquine-artesunate versus amodiaquine were: 175/192 (91%) versus 140/188 (74%) in Kenya (D=16.7% [95% CI 9.3-24.1], p<0.0001), 148/160 (93%) versus 147/157 (94%) in Sénégal (-1.1% [-6.7 to 4.5], p=0.7), and 92/94 (98%) versus 86/96 (90%) in Gabon (8.3% [1.5-15.1], p=0.02). The corresponding rates for day 28 were: 123/180 (68%) versus 75/183 (41%) in Kenya (27.3% [17.5-37.2], p<0.0001), 130/159 (82%) versus 123/156 (79%) in Sénégal (2.9% [-5.9 to 11.7], p=0.5), and 80/94 (85%) versus 70/98 (71%) in Gabon (13.7% [2.2-25.2], p=0.02). Similar rates were obtained by evaluability analysis. INTERPRETATION: The combination of artesunate and amodiaquine improved treatment efficacy in Gabon and Kenya, and was equivalent in Sénégal. Amodiaquine-artesunate is a potential combination for use in Africa. Further investigations to assess the potential effect on the evolution of drug resistance, disease transmission, and safety of amodiaquine-artesunate are warranted.

Trabeculectomy with and without mitomycin-C in a black African population.

PURPOSE: To evaluate the beneficial effects of intraoperative application of mitomycin-C during trabeculectomy in a black African population in Congo-Kinshasa. METHODS: A prospective randomized study in 22 eyes (11 patients) with open-angle glaucoma. All patients underwent trabeculectomy with application of mitomycin-C (0.4 mg/ml for 2.5 min) under the scleral flap in the right eye and trabeculectomy alone in the left eye. Assessment of the clinical outcome included intraocular pressure, visual acuity, visual field and complications. The follow-up was 20 months. Success of the filtering surgery was defined as a final IOP of 21 mmHg or lower without antiglaucoma medications and no further glaucoma surgery necessary. RESULTS: The success rate of trabeculectomy was 81.8% in eyes treated with mitomycin-C compared with 63.6% in eyes not receiving this drug. Rates of intraocular pressure reduction were 57.9% and 42.9% respectively. Complications occured in 36.3% of the eyes managed with mitomycin-C against 9% in the control eyes. CONCLUSIONS: Mitomycin-C, as adjunctive treatment during trabeculectomy in black Africans, offers great benefit in lowering IOP, but with a substantial high risk of complications. These data need to be confirmed by further studies in this population.

Reconstruction of orbital floor blow-out fractures with silicone implant.

AIM: To evaluate the outcome of orbital floor blow-out fractures treated surgically with silicone implant. METHODS: The patients were examined in a prospective study from October 1993 to December 1999. Over this period 11 patients were diagnosed as having orbital floor blow-out fractures. The study was restricted to those who were both treated surgically and followed-up at least three months after the discharge from hospital. Only six patients (five males and one female), ranging in age from 6 to 30 years, fulfilled the inclusion criteria. The fractures occurred during brawls in 3 patients, car accidents in 2 patients and child's play in 1 patient. The diagnosis was based on history, clinical grounds and coronal computed tomography. The surgical procedure was the same in all patients, using silicone implant to reconstruct the defects. The mean follow-up time after surgery was 4.8 months. RESULTS: The interval between injury and diagnosis ranged from 6 to 85 days (mean: 34.8 days). Limitation of vertical eye movements was present in all 6 patients, diplopia in 4 patients, enophthalmos in 3 patients and hypoesthesia in the distribution of the infraorbital nerve in 1 patient. The mean interval time between injury and surgery was 55.3 days and the majority of the patients (83%) had late repairs (> 14 days) after injury. Postoperatively, satisfactory results were obtained with regard to limitation of vertical eye movements, diplopia, enophthalmos and hypoesthesia. Only one patient had a persistent and partially reduced enophthalmos. Silicone implant was well tolerated in all 6 cases since complications such as infection, tissue reaction and extrusion were not observed. CONCLUSION: Satisfactory results may be obtained after late repair of orbital floor blow-out fractures. Silicone implant has the potential to be used successfully in orbital floor fractures.

Uveitis in HIV-infected patients.

PURPOSE: To determine the prevalence of HIV infection and to find out the possible causes (associated conditions) of uveitis in HIV-infected patients. METHODS: We retrospectively analyzed the data of 581 patients with uveitis diagnosed over an 11-year period. All patients received a routine eye examination and most of them a general examination as well as complementary tests. RESULTS: The prevalence of HIV infection was 14.3% (89 patients). Anterior uveitis (62%) was the most frequent form, followed by posterior uveitis (22%), panuveitis (12%) and intermediate uveitis (4%). Associated conditions or causes were found in 88% of these 89 patients, the most frequent being Herpes zoster ophthalmicus (43%), tuberculosis (16%), CMV infection (12%) and toxoplasmosis (10%). CONCLUSIONS: In HIV-infected patients uveitis is frequently associated with opportunistic infections.

[Corneal complications of traditional local ocular treatment in the Democratic Republic of the Congo]. / Complications cornéennes des traitements traditionnels locaux oculaires en République Démocratique du Congo.

The purpose of this retrospective study was to determine the relationship between the use of local traditional eye medicine and the occurrence of corneal ulcers. The study population included 53 patients who consulted from January 1998 to October 1999 at two hospitals in Kinshasa, Democratic Republic of the Congo, after visiting a traditional healer. Clinical examination of the eye was performed in all cases and bacteriological tests in most. Local traditional eye medicine is used in both urban and rural areas. Factors associated with the use of local traditional eye medicine include level of education and social class. A cause-and-effect relationship was found between the use of local traditional eye medicines and development or worsening of corneal ulcers. Peripheral corneal ulcers were the most common. Corneal perforation was more frequent in association with peripheral ulcers. Use of traditional eye medicine often leads to corneal ulcers with perforation and destruction of the eye in most cases. For this reason these practice must be curtailed. However further study is needed to identify the active agents in plants used by traditional healers as well as to determine their efficacy and toxicity for the eye.

[Uveitis in patients with HIV infection]. / Uvéite chez les patients infectés par le VIH.

We carried out a retrospective analysis of 581 patients with uveitis seen over an 11-year period, to determine the prevalence of HIV infection in these patients and to look for associated diseases and the possible causes of uveitis in HIV-infected patients. All patients underwent routine eye examination and most also underwent a general examination and complementary tests. The prevalence of HIV infection was 14.3% (89 patients). Anterior uveitis (62%) was the most frequent, followed by posterior uveitis (22%), panuveitis (12%) and intermediate uveitis (4%). Associated conditions or causes were identified in 88% of the HIV-infected patients, with herpes zoster ophthalmicus the most frequent (43 %), followed by tuberculosis (16%), CMV infection (12%) and toxoplasmosis (10%). Thus, uveitis in HIV-infected patients is frequently associated with opportunistic infections.

Ophthalmologic abnormalities in mentally retarded.

PURPOSE: To determine the prevalence and types of ophthalmologic abnormalities in mentally retarded subjects. METHODS: Seventy-three institutionalized mentally retarded subjects (41 boys and 32 girls) aged 5 to 19 years (mean: 11.5 years) were examined ophthalmologically during a three month period (from May to July 1999). The eye examination consisted of visual acuity testing (illiterate Snellen E-chart or acuity card procedures), pupillary reflex and motility evaluation, cover test for phoria and tropia, examination of adnexa and anterior segment (magnifying glass or slit-lamp biomicroscopy if indicated and possible), retinoscopy and direct ophthalmoscopy. All subjects were evaluated pediatrically, neurologically, psychologically and otorhinolaryngologically if indicated. RESULTS: Ophthalmologic abnormalities were found in 60.2% of the subjects. Eyelid abnormalities accounted for 21.7%, fundus abnormalities for 21.6%, refractive errors for 15% and ocular motility disorders for 13.6%. Taken separately, optic atrophy (16.4%) was the most frequent disorder, followed by refractive errors (15%), hypertelorism (12.3%), epicanthus (10.9%) and nystagmus (8.2%). Strabismus and mongoloid obliquity of lids were seen in 5.4% each other while ptosis was disclosed in 4.2% of cases. Visual acuity tested in 60 subjects revealed that 25 (41.6%) had visual impairment. Of all subjects 10.9% required corrective glasses while 9.6% needed corrective surgery for strabismus and ptosis. CONCLUSION: This study shows a high prevalence of ophthalmologic abnormalities in mentally retarded subjects. This is in agreement with the results of several other previous studies. It's therefore essential to screen mentally disabled subjects ophthalmologically.